6.5 Pressure Injury Prevention, Staging, and Treatment Scenarios
Key Takeaways
- Pressure injury scenarios combine risk assessment, skin inspection, support surfaces, repositioning, moisture control, nutrition, and documentation.
- Staging depends on tissue depth and visibility, not on wound size, drainage amount, or pain alone.
- Deep tissue pressure injury, unstageable pressure injury, and mucosal injury are common classification traps.
- The exam trap is focusing on the wound dressing while leaving pressure, shear, moisture, or device pressure uncorrected.
Pressure injury scenarios start with force
Pressure injury content spans several official WCC domains: Assessment covers skin integrity, wound status, risk tools, function, cognition, nutrition, pain, and comorbidities; Treatment covers support surfaces and wound treatments; Risk and Prevention covers impaired skin integrity and at-risk populations. The exam expects an integrated plan, not just staging labels.
Pressure injuries result from pressure, often with shear, over bony prominences or from devices. Prevention starts with identifying immobility, sensory loss, moisture, poor nutrition, perfusion problems, medical devices, friction, pain, sedation, cognitive impairment, and inability to reposition. Treatment starts with removing or reducing the cause.
| Classification issue | Key exam cue | Common trap |
|---|---|---|
| Stage 1 | Intact skin with nonblanchable erythema | Calling it not a wound because skin is intact |
| Stage 2 | Partial-thickness skin loss or blister pattern | Mislabeling moisture-associated damage as pressure |
| Stage 3 | Full-thickness skin loss with adipose visible | Calling it Stage 2 because bone is not exposed |
| Stage 4 | Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone | Staging by size instead of depth |
| Unstageable | Full-thickness loss obscured by slough or eschar | Guessing the stage before the base is visible |
| Deep tissue pressure injury | Persistent deep red, maroon, or purple discoloration or blood-filled blister | Waiting for skin to open before acting |
Applied WCC scenario guidance: a bedbound patient has a dark purple heel area that is intact and painful. The best answer is not to massage it or wait until it opens. The candidate should offload the heel, assess perfusion, protect the skin, notify according to policy, document the discoloration, review support surfaces and turning, and monitor for evolution.
Staging is not based on wound size, drainage, infection, or pain. A small Stage 4 can be deeper than a large Stage 2. A wound covered with slough or eschar is unstageable until enough base is visible to determine depth, unless the correct category is a deep tissue pressure injury. Mucosal pressure injuries are not staged with the same numeric system.
Treatment decisions must address pressure and shear. Repositioning, support surfaces, heel offloading, transfer technique, head-of-bed management, moisture control, nutrition referral, pain management, and device checks are central. A sacral foam dressing may protect skin, but it does not correct sliding in bed or prolonged chair sitting.
Device-related pressure is a recurring trap. Oxygen tubing, masks, cervical collars, casts, splints, compression wraps, urinary tubing, and footwear can injure tissue. The WCC candidate should inspect under and around devices, pad or reposition according to policy, and communicate with the team.
Exam trap: massaging reddened skin or using a donut cushion. Another trap is reverse staging, such as documenting that a healing Stage 4 is now a Stage 2. Healing pressure injuries should be described by original stage and current characteristics.
Documentation should include location, stage or category, size, tissue, drainage, odor, pain, periwound, undermining or tunneling, risk score or risk factors, support surface, turning plan, heel plan, moisture plan, nutrition referral, education, and response. This supports treatment, prevention, and legal domains.
An intact heel has persistent purple discoloration and pain after prolonged immobility. What is the best WCC exam response?
A full-thickness pressure injury is completely covered by slough, so the base cannot be seen. How should it be classified?
What is the pressure injury treatment trap?